Provider Demographics
NPI:1003678202
Name:DIAZ DOMINGUEZ, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:DIAZ DOMINGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4090 BELLE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-2705
Mailing Address - Country:US
Mailing Address - Phone:956-309-2440
Mailing Address - Fax:
Practice Address - Street 1:3066 S JOG RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-2053
Practice Address - Country:US
Practice Address - Phone:561-788-4086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-158784106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician